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1 WEST LIBERTYCOMMUNITY SCHOOL DISTRICT Nurse Application for Employment FULL NAME LAST FIRST MIDDLE INITIAL DATE OTHER NAME(S) PLEASE PROVIDE ANY OTHER NAMES YOU HAVE USED AT ANY TIME CURRENT ADDRESS STREET CITY STATE ZIP HOW LONG AT CURRENT TO: FROM: PREVIOUS ADDRESS ADDRESS STREET CITY STATE ZIP TELEPHONE HOME:( ) CELL: ( ) SOCIAL SECURITY NO. NOTE: SOCIAL SECURITY NUMBER IS OPTIONAL AND FAILURE TO SUBMIT IT ON THIS FORM WILL NOT PROHIBIT EMPLOYMENT CONSIDERATON. SOCIAL SECURITY NUMBER MAY BE REQUIRED ON OTHER FORMS BEFORE EMPLOYMENT. POSITION APPLYING FOR: INDICATE PREFERENCE: FULL-TIME PART-TIME SUBSTITUTE MONTH/DAY/YEAR AVAILABLE FOR EMPLOYMENT: IOWA NURSING LICENSE NUMBER: DRIVER S LICENSE NUMBER (IF REQUIRED FOR POSITION): IMPORTANT ADDITIONAL REQUIREMENTS 1. In addition to completing this application, you should provide a copy of your applicable nursing license and all college transcripts (unofficial acceptable at this point). 2. Upon receipt of a conditional offer of employment, the applicant must provide a complete original transcript of credits and certification of employment eligibility in the United States. DO YOU KNOW ANY WEST LIBERTY BOARD MEMBER OR EMPLOYEE(S), RELATIVE(S) OR FRIEND(S) EMPLOYED BY WEST LIBERTY AND, IF YES, DESCRIBE THE RELATIONSHIP. Yes No

2 EMPLOYMENT EXPERIENCE: (LIST CHRONOLOGICALLY STARTING WITH MOST RECENT) 1 NAME OF EMPLOYER INSTITUTION/LOCATION POSITION HELD DATES (FROM/TO) FT/PT REASON FOR LEAVING SUPERVISOR EDUCATIONAL PREPARATION (LIST CHRONOLOGICALLY STARTING WITH MOST RECENT) EDUCATION High School College/University NAME OF SCHOOL OR UNIVERSITY/LOCATION MAJOR WAS A DEGREE OBTAINED? Y/N IF NOT, NUMBER OF HOURS EARNED. TYPE OF DEGREE EARNED START/END DATE (SPECIAL TRAINING OR INSTRUCTION AND/OR CERTIFICATION NOT LISTED ABOVE) INSTITUTION/LOCATION/COMPANY COURSE OR PROGRAM CREDIT EARNED (IF ANY) CONTRACT STATUS 1. ARE YOU CURRENTLY UNDER CONTRACT? YES NO IF YES, WHERE? PRESENT POSITION: SUBSTITUTE PROBATIONARY CONTINUING (TENURED) 2. HAVE YOU CHECKED AND CAN YOU BE RELEASED IF YOU ARE OFFERED ANOTHER POSITIONS? YES NO IF NO, EXPLAIN 3. WHY DO YOU WISH TO LEAVE YOUR CURRENT POSITION FOR A POSITION IN WEST LIBERTY COMMUNITY SCHOOL DISTRICT?

3 REFERENCES & SUPERVISOR INFORMATION IT IS THE APPLICANT S RESPONSIBILITY TO HAVE THE FOLLOWING INFORMATION PROVIDED TO WEST LIBERTY COMMUNITY SCHOOL DISTRICT TO BE CONSIDERED FOR EMPLOYMENT. PROVIDE THE NAMES OF YOUR THREE MOST RECENT SUPERVISORS AND TWO PROFESSIONAL REFERENCES. I. SUPERVISORS 1. NAME POSITION 2. NAME POSITION 3. NAME POSITION II. REFERENCES 1. NAME POSITION 2. NAME POSITION IS A PLACEMENT FILE BEING SENT: Yes No

4 BACKGROUND CHECK INFORMATION: In addition to the following information, a thorough background check may be made at the option of the West Liberty Community School District. YES answers to the following questions will not necessarily result in denial of employment. We will consider all the circumstances, including the date and nature of events that led to the actions described below. Your written explanation will assist us in determining your eligibility and suitability for employment. Please note that your failure to provide complete, truthful and accurate information will most likely lead to West Liberty Community School District not hiring you and/or, if you are hired, terminating your employment upon the discovery of the incorrect, false or inaccurate information. A. Have you ever been convicted of, admitted committing, pleaded no contest, or are you awaiting trial for any crime (excluding only minor traffic violations that do not involve any allegations of alcohol, drugs, or reckless driving) or have any civil charges previously or pending involving allegations of child or dependent adult abuse or spousal abuse? You must answer YES even if the matter was later dismissed, deferred, reversed, or vacated. If you answer YES to any of the following, on a separate sheet of paper attach and provide an explanation including dates of the proceedings, the name and address of the court and/or employer or licensing body where the proceedings occurred, a statement of the accusation against you and the final disposition of the matter. No Yes, attach a separate sheet for explanation. B. Have you ever been dismissed (fired) from any job, or resigned at the request of or pressure from your employer, or left employment while charges or an investigation of your behavior was pending or been refused tenure, reappointment or continuing contract from any employer? You must answer YES even if the matter was later resolved with any form of settlement or severance agreement, regardless of the terms. If you answer YES you must provide the date of termination or resignation and other action concerning tenure, reappointment or continuing contract denial, and the name, address and telephone number of the employer(s) and a statement of the alleged reasons for termination or resignation. No Yes, attach a separate sheet for explanation. C. Have you ever had any license or certificate of any kind (teaching certificate or other professional license) revoked, suspended, or reprimanded, or have you in any way been sanctioned, or is any charge or complaint now pending against you before any licensing, certification or other regulatory agency or body, public or private? If you answer YES you must provide the dates of proceedings, name, address and telephone number of the agency or body or employer and where proceedings took place, a statement of the accusations against you, the final disposition and/or current status of the charge or complaint. No Yes, attach a separate sheet for explanation.

5 TO WAR-TIME VETERANS: Special Notice - Voluntary Information: Iowa Code Chapter 35C requires public employers to inquire whether applicants served in the military or naval forces during wars or armed conflicts. If an applicant meets certain eligibility criteria, they may be entitled to preference in employment. Please indicate below whether you wish West Liberty Community School District to determine whether you are qualified for this preference. Yes No If you marked YES, please fill out the page entitled Voluntary Information Time Veteran. War VERIFICATION STATEMENT I hereby certify that the information in this Application for Employment is true, correct, and complete to the best of my knowledge. I certify that I have answered all questions to the best of my ability and I have not withheld any information that would unfavorably affect my application for employment. I also understand and acknowledge that if I am employed by West Liberty Community School District that any misrepresentation or omission of any fact whenever discovered in my application, resume or any other materials, or during any interviews, may be the cause for my rejection from employment or may result in my subsequent dismissal if I am hired. I also understand that if I accept a position with West Liberty Community School District, the statements on this application will become part of my permanent record. I also understand that an offer of employment is conditioned upon the completion of a satisfactory background check which may include, but is not limited to the following: educational verification, background information, criminal, child abuse registry, and a department of transportation (DOT) driving record verification (if a driver s license is required for the position applied). I also understand and agree that with my signature on this document I give permission to West Liberty Community School District to conduct: 1) Criminal History Records Check, 2) Child Abuse Registry Check, 3) a Driver s Record Check, 4) education verification, and 5) background information. Finally, I acknowledge and understand that before an offer of employment would be made, I would have to agree to and sign a Background and Employment Information Authorization and Release. SIGNATURE OF APPLICANT DATE West Liberty Community School District provides equal opportunity in employment to all persons regardless of age, race, creed, color, sex, national origin, religion or disability. WEST LIBERTY COMMUNITY SCHOOL DISTRICT 203 E 7 th Street West Liberty, Iowa 52776

6 VOLUNTARY INFORMATION VETERAN If an applicant meets certain eligibility criteria, and there are no other applicants with greater qualifications, an eligible and qualified veteran may be entitled to preference in employment under Iowa Code 35C.1. A veteran is an individual who meets the definition set forth in Iowa Code If the applicant indicates below that he/she is a veteran, the District may perform a background check into the applicant s military service record for verification of eligibility under Chapter 35C. Refusal to provide this information will not adversely affect your consideration for employment. If you wish to be identified as a veteran, please check any of the categories indicated below that are applicable to your status as a veteran. I AM AN HONORABLY DISCHARGED CITIZEN AND RESIDENT OF THE STATE OF IOWA, WHO SERVED IN THE ARMED FORCES OF THE UNITED STATES AT SOME TIME DURING THE FOLLOWING DATES: World War II from December 7, 1941 through December 31, 1946 or a former member of the active, oceangoing merchant marines who served at any time within those dates and was honorably discharged or a former member of the women's air force service pilots or another person who has been conferred veterans status based on my civilian duties during World War II in accordance with federal Pub. L. No , 38 U.S.C Korean conflict from June 25, 1950 through January 31, 1955 or a former member of the armed forces of the United States and a portion of my time of enlistment occurred within those dates, but I instead opted to serve five years in the reserve forces of the United States, as allowed by federal law, and I was discharged under honorable conditions. Vietnam conflict from February 28, 1961 through May 7, Lebanon or Grenada service from August 24, 1982 through July 31, Panama service from December 20, 1989 through January 31, Persian Gulf conflict from August 2, 1990 and ending on the date specified by the President or Congress of the United States as the date of permanent cessation of hostilities. I am a former member of: the reserve forces of the United States who served at least twenty years in the reserve forces after January 28, 1973, and who was discharged under honorable conditions. the reserve forces of the United States who completed a minimum aggregate of ninety days of active federal service, other than training, and was discharged under honorable conditions, or was retired under Title X of the United States Code. the Iowa national guard who served at least twenty years in the Iowa national guard after January 28, 1973, and who was discharged under honorable conditions. the Iowa national guard who was activated for federal duty, other than training, for a minimum aggregate of ninety days, and was discharged under honorable conditions or was retired under Title X of the United States Code. The undersigned,, applicant hereby authorizes any veteran, military, or other government agency to provide information which is necessary to verify applicant s eligibility for veterans preference to West Liberty Community School District, 203 E. 7 th Street, West Liberty, Iowa Any information acquired by the West Liberty Community School District under this authorization shall be for their confidential use only. Furthermore, the West Liberty Community School District will use the information acquired under this authorization solely to determine the applicant s eligibility for a veterans preference only in the position applied for. APPLICANT S SIGNATURE DATE

7 BACKGROUND AND EMPLOYMENT INFORMATION AUTHORIZATION AND RELEASE The undersigned,, (hereinafter Prospective Employee ) hereby authorizes any present ٱ or former ٱ employer to provide information about his/her background for employment purposes to West Liberty Community School District, 203 E. 7 th Street, West Liberty, Iowa 52776, a prospective employer (hereinafter West Liberty ), who may make such an informational request. Information to be appropriately released may include, without being limited to: Positions held Training Performance evaluations Experience Professional assessment of strengths, skills, abilities Qualifications Attendance record Professional conduct Criminal record Confirming dates of employment Other information pertinent to the position applied for Reasons for leaving employment Reasons why or why not rehire Any information acquired by West Liberty Community School District under this authorization shall be for their confidential use only, and shall not be communicated in any way to other employers, agencies, educational institutions or any other business or organization requesting such information for any purpose. Furthermore, West Liberty Community School District shall use the information acquired under this authorization solely to determine the applicant s fitness for the position available or to verify credentials claims and/or other information supplied by the applicant. The undersigned Prospective Employee, to the extent permitted by law, hereby releases the former employer from any and all liability resulting from the release of the aforesaid information to West Liberty Community School District. This Release covers all injuries, damages, and claims whether known or not and which may hereafter appear or develop, arising from the providing of such information as authorized above. Specifically, the undersigned agrees to discharge the former employer, its agents or employees from any and all claims resulting from or due to the good faith release of information arising under: breach of contract; interference with contractual relations; unintentional misrepresentation; any violation of a State or Federal constitution; invasion of privacy; defamation/slander; or any other federal or state violation or cause of action including the undersigned s individual contract and employment or applicable collective bargaining agreement, whether currently in effect or previously in effect. Prospective Employee s Signature Date Print Name Witness Signature

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